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According to MSF, across the world, in every country and every population group, some 15 percent of pregnant women develop complications that are potentially life-threatening.

The most common causes of maternal death are haemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour.

"Access [to emergency services] is really important," said MSF head in Sierra Leone Jose Hulsenbeck. "If we just had the obstetric care without ambulances, the numbers may have been very different."

MSF originally set up in Bo, working with Liberian refugees and Sierra Leonean returnees at Gondama camp, just outside of town.

What about midwives?

Health workers and aid agencies have stressed the need for better reproductive health care at the local health clinic level, including better support to train qualified midwives. Even with an ambulance, some remote areas are unreachable in the rainy season.

But support to emergency care does not negate the need for more qualified midwives, said Hulsenbeck.

Without better continual care, providing good emergency services is also complicated, as patient history may be murky, said Liebeth Leysen, head of the project in Bo.

"Yes, you need midwives in clinics. On the other hand a high percentage of women have problems during delivery. If you don't have that care, even with midwives, you could still have problems saving the life of a woman and her child," said Hulsenbeck. "It is not one or the other. These should operate parallel to each other."

Sustainability

MSF will continue in Bo for years to come, but over the long term, it is up to governments to lead on improving maternal health care, say aid agencies.

The project has cost MSF US$9 million per year since 2008. "For this project to work in other parts of Sierra Leone, there needs to be a lot of awareness-raising of the problem of maternal mortality," said Leysen.

The government removed user fees for pregnant women and infants, but in this cash-strapped economy, programmes have met with hiccups.

According to the World Health Organization (WHO), every year some 287,000 women die from complications during pregnancy and childbirth. Most of them were young, active and healthy.

Children whose mothers die giving birth to them are 10 times more likely to die prematurely, while - without a mother to care for them - older children in the family are also at increased risk, according to WHO.

Across sub-Saharan Africa maternal mortality rates fell 41 percent between 1990 and 2010, according to the UN Population Fund.